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THCB Reader Mail (from Maggie Mahar & Jeff Goldsmith)

Frequent THCB contributor Maggie Mahar responds to Matthew’s post last week on decision aids:

"Too often, "patient satisfaction" is based on trivial things that have little or nothing to do with the quality of care. For example, a patient may have to wait two hours to a see a doctor because the doctor was called into surgery, because earlier in the day what he thought would be a routine 20 minute visit turned into an emergency. Or maybe he just spent 10 or 15 minutes longer with each of 5 patients because they had questions.

I once spent five hours listening in while the head of cardiology at a major medical center saw patients. All of these things happened except being called into surgery. One patient showed up, without an appointment, who had begun losing his vision in one eye that morning. A very bad sign. He needed immediate attention.

Another patient’s test showed that his carotid artery was totally blocked. In other words, he shouldn’t be alive. (The doctor was completely shocked). But there he was, sitting there, 85 years old, with a flock of his octogenarian relatives. It took a while to explain to all of them what was going on and why he needed immediate surgery.

Then there was the CEO scheduled for a bypass in four weeks who wanted to put it off because he wanted to wait three months until the end of the golf season. (He had already collapsed on the golf course, which was when he was diagnosed.) He also wondered why he couldn’t have the surgery at a hospital near his home in the surburbs rather than at the medical center in NYC. "It’s so hard to park here," he explained. "And it’s expensive." I wanted to stand up and scream: "You’re having open-heart surgery! Hire a car!"   

Throughout all of this the head of cardiology was extremely patient,
explained things 4 different ways until patients understood.  How could
he possibly predict how long this would take? Later, he explained to
me: "They’re afraid. And when people are afraid, they’re often
irrational."

Medicine is full of uncertainties and surprises. A three hour
surgery can easily turn into a five hour surgery if the surgeon finds
something he didn’t expect when he opens the patient up. This happens
all of the time in general surgery. Every human body is unique–which
leads to surprises.

Up next, we have a little Clintonology from Jeff Goldsmith:

The Clintons overestimated the amount of economic insecurity in the
voting public in 1994. The 1990-91 recession was concentrated on
Democratic turf-the Northeast and far West Coast, and was led by a
sharp downturn in defense spending after the collapse of the Soviet
Union. The South and Midwest, with limited defense contracting, barely
noticed. The last serious recession in those parts of the country was
27 years ago. Southerners and Midwesterners elected George Bush
President. A little more fear isn’t necessarily going to produce a
better health reform outcome.

The Clintons also overestimated the level of voter trust in
government and in them. Ezra’s most important statistic- 94% of voters
already HAVE health insurance (that number was probably higher in
1994). The Clintons proposed to federalize private health insurance,
with brand new government agencies collecting premiums from employers
and dispersing them to health plans. They also relied on a mechanism of
paying for care that was unproven and required completely re-organizing
the care system into risk bearing economic units. A technocratic dream;
a political nightmare. The plan was laughably, killingly complex,
administratively infeasible, financially opaque and a huge execution
risk. Other than that, it was a great plan.

Remember Ronald Reagan’s "the federal government is the problem"
was still alive and well in the electorate, only 43% of whom voted for
Bill Clinton. The public was right to be skeptical. It was far from
clear that the Clintons’ plan would have helped the voting public (it
might have created a lot more Democratic voters, however, among the
newly insured). Thanks to Katrina, the bungled war in Iraq and a host
of other things, voter trust in governmental competence and in
politicians is far lower than 1994, and their tolerance for opaque,
difficult to understand policies (and technocrats) is virtually
non-existent. Technocrats "planned" and executed the War in Iraq.

Third (and an area where Hillary’s "learning experience" in 1994
would actually help her in 2009 should she make it to the White House),
trust between the Executive Branch and Congress was low in 1994 (and is
far lower now). The Clinton White House treated Congressional leaders
like children. They actually threatened to "roll" the Democratic
Chairman of the Senate Finance Committee if he didn’t co-operate, and
to "demonize" any House Democrats that didn’t fall in line. Moynihan
believed, correctly, that welfare reform was not only more doable but
perhaps also, more important, than health reform, and never got a
chance to state his case. Also remember, the Clintons had Democratic
majorities in both houses of Congress in 1994. If they’d delivered
THEIR OWN PEOPLE, and found about five Republican Senate votes, they
could have pulled it off. It didn’t have to be bipartisan, but the
process did have to be accessible and flexible. It was neither. They
seriously pissed off the Democratic leadership and particularly
Democratic moderates in both Houses by treating them like stepchildren
in the political process, and got nowhere.

Unless there is a Democratic landslide next year, which ain’t going
to happen, it will take bipartisan support to pass health reform
legislation. Ezra’s suggestion that keeping the Jerry Springer
political mudfight over SCHIP alive for another year will make it
easier to pass health reform is delusional nonsense. Republicans "don’t
hate kids" and Democrats don’t want "socialized medicine". Voters are
tired of this crap, and the polarized, cartoon-like, poll-driven
calculation behind it. That’s why Obama and McCain are still alive in
their respective primaries.

It is going to take a ton of pragmatism and old fashioned deal
making to make health reform happen, as well as a recommitment of
Americans to the political process. American Prospect’s Paul Starr had
it right in the inaugural issue of the publication seventeen years ago-
unless Americans’ faith in the efficacy of government and the political
process is restored, the progressive political agenda is not going
anywhere. Right on, Paul. That’s the heart of the problem- convincing
the 94% of the voting population with health insurance that they are
going to be better off after the health reform process than before.
That’s a fairly high bar. . .

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